Sara82
Guru
Sumary of Operative report below. I billed 27514(dx 821.21), 27580(dx 733.82) and 11982. CPT 27580 came back denied as not recommended for seperate reinbursement with CPT 27580. There are not edits so would I add a 51 modifier to 27580 or can I just not bil 27514 with 27580?
POSTOPERATIVE DIAGNOSIS:
Previously infected knee replacement with soft tissue problems
and extensor mechanism dislocation and medial femoral condyle
fracture.
OPERATION PERFORMED:
1. Irrigation and debridement of the knee.
2. Removal of antibiotic spacer.
3. Knee fusion.
4. Open reduction and internal fixation of medial condyle
fracture and nonunion.
DESCRIPTION OF OPERATION:
Her previous midline incision was utilized. We went medially around the skin graft. Small flaps were elevated off the extensor mechanism. The extensor mechanism was opened through a medial parapatellar
approach. There was a bloody fluid present in the knee. The
spacer block was freely mobile in there. The medial femoral
condyle was broken off with a nonunion. Ultimately the spacer
block was removed. Cultures were taken. The Gram stain was
called back as no organisms. A frozen section was taken as well
which was called back as without evidence of acute inflammation.
This was all felt to be at least response to the adequate
treatment of her infection. We then proceeded with the knee
fusion. The bony surfaces were completely curetted off. The
canals were curetted free as well. We assessed our bony defects.
The nonunion was taken down and the bony edges of the medial
femoral condyle freshened up as well. The tibial canal was
curetted out and all the cement was removed from here. We packed
the tibial canal to prevent debris from entering and turned our
attention to the femur. The femur was reamed to accept the 18 mm
Wichita nail stem. This was impacted into place. Once we
confirmed that it would fit, we assessed our bony defects. We
placed an intramedullary guide and cut the lateral femoral
condyle which was impacted 0 degrees to give us a reasonable bony
surface. We cut the medial femoral condyle which was loose as
well in a way that would allow us to reduce it into the fusion
site at the end. Happy with this, the rod was placed up the
femur and tapped into place. C-arm fluoroscopy was utilized to
confirm good position. The proximal Prostalac screws were placed
under standard technique with two 30 mm Prostalacs. This was
nice and rigid. It should be mentioned that rotation was marked
on both the tibia and the femur prior to starting. We assessed
the position of the leg and the position of the other leg to
provide a little bit of external rotation. Happy with the
fixation of the femur, we turned our attention to the tibia. A
freshening cut was made on the tibial surface with just a couple
degrees of slope. We had reasonable bone here as well and a nice
flush surface. The canal was reamed to accept a 12 mm tibial
rod. This was actually quite tight distally. C-arm fluoroscopy
was utilized to confirm good position and straight alignment.
Once we were happy with this, the final rod was assembled and
impacted into place. We cut out the square of the tibia and
turned this into bone graft. The proximal Prostalac screws were
placed here as well. The distal Prostalac screws were not placed
as this was very tightly engaged in the cortex. Happy with this,
we assessed our rotation and happy with this, engaged the nail.
We removed the proximal jig. The compression screw was placed
on the rod and we engaged them both together and compressed. We
actually had quite good contact laterally. Pretty good flush
surfaces that really compressed quite nicely. We were able to
shape the medial femoral condyle piece and reduced this in as
well. We held this in place and placed a single 65 cancellous
screw diagonally across the piece and down into the tibia which
actually compressed it into the union site quite nicely. Overall
rotation and alignment of the leg was checked with C-arm
fluoroscopy which was confirmed to be good. Happy with this, all
the bone that we had removed was curetted out and placed in the
fusion site for bone graft. The wound was again copiously
irrigated with antibiotic solution. A single drain was placed.
We used a rongeur to ______ the patella as well down to a little
nubbin. The extensor mechanism was then closed with 0 Vicryl
suture in interrupted fashion. Subcutaneous tissues were
reapproximated with 2-0 Vicryl suture. Skin was reapproximated
with staples. The patient was awakened and transferred to
recovery room with a knee immobilizer, in stable condition.
POSTOPERATIVE DIAGNOSIS:
Previously infected knee replacement with soft tissue problems
and extensor mechanism dislocation and medial femoral condyle
fracture.
OPERATION PERFORMED:
1. Irrigation and debridement of the knee.
2. Removal of antibiotic spacer.
3. Knee fusion.
4. Open reduction and internal fixation of medial condyle
fracture and nonunion.
DESCRIPTION OF OPERATION:
Her previous midline incision was utilized. We went medially around the skin graft. Small flaps were elevated off the extensor mechanism. The extensor mechanism was opened through a medial parapatellar
approach. There was a bloody fluid present in the knee. The
spacer block was freely mobile in there. The medial femoral
condyle was broken off with a nonunion. Ultimately the spacer
block was removed. Cultures were taken. The Gram stain was
called back as no organisms. A frozen section was taken as well
which was called back as without evidence of acute inflammation.
This was all felt to be at least response to the adequate
treatment of her infection. We then proceeded with the knee
fusion. The bony surfaces were completely curetted off. The
canals were curetted free as well. We assessed our bony defects.
The nonunion was taken down and the bony edges of the medial
femoral condyle freshened up as well. The tibial canal was
curetted out and all the cement was removed from here. We packed
the tibial canal to prevent debris from entering and turned our
attention to the femur. The femur was reamed to accept the 18 mm
Wichita nail stem. This was impacted into place. Once we
confirmed that it would fit, we assessed our bony defects. We
placed an intramedullary guide and cut the lateral femoral
condyle which was impacted 0 degrees to give us a reasonable bony
surface. We cut the medial femoral condyle which was loose as
well in a way that would allow us to reduce it into the fusion
site at the end. Happy with this, the rod was placed up the
femur and tapped into place. C-arm fluoroscopy was utilized to
confirm good position. The proximal Prostalac screws were placed
under standard technique with two 30 mm Prostalacs. This was
nice and rigid. It should be mentioned that rotation was marked
on both the tibia and the femur prior to starting. We assessed
the position of the leg and the position of the other leg to
provide a little bit of external rotation. Happy with the
fixation of the femur, we turned our attention to the tibia. A
freshening cut was made on the tibial surface with just a couple
degrees of slope. We had reasonable bone here as well and a nice
flush surface. The canal was reamed to accept a 12 mm tibial
rod. This was actually quite tight distally. C-arm fluoroscopy
was utilized to confirm good position and straight alignment.
Once we were happy with this, the final rod was assembled and
impacted into place. We cut out the square of the tibia and
turned this into bone graft. The proximal Prostalac screws were
placed here as well. The distal Prostalac screws were not placed
as this was very tightly engaged in the cortex. Happy with this,
we assessed our rotation and happy with this, engaged the nail.
We removed the proximal jig. The compression screw was placed
on the rod and we engaged them both together and compressed. We
actually had quite good contact laterally. Pretty good flush
surfaces that really compressed quite nicely. We were able to
shape the medial femoral condyle piece and reduced this in as
well. We held this in place and placed a single 65 cancellous
screw diagonally across the piece and down into the tibia which
actually compressed it into the union site quite nicely. Overall
rotation and alignment of the leg was checked with C-arm
fluoroscopy which was confirmed to be good. Happy with this, all
the bone that we had removed was curetted out and placed in the
fusion site for bone graft. The wound was again copiously
irrigated with antibiotic solution. A single drain was placed.
We used a rongeur to ______ the patella as well down to a little
nubbin. The extensor mechanism was then closed with 0 Vicryl
suture in interrupted fashion. Subcutaneous tissues were
reapproximated with 2-0 Vicryl suture. Skin was reapproximated
with staples. The patient was awakened and transferred to
recovery room with a knee immobilizer, in stable condition.